Story of Ah Huat

Ah Huat, age 37, is a calm and shy man attending a day care centre. He experiences difficulties in carrying out most of his Activities of Daily Living (ADL). He is unable to eat independently without spillage. He also needs help with cleaning himself after using the toilet. He requires assistance from his elderly mother for showering and dressing up. As Ah Huat’s mother grows older, caring for him will no longer be an easy task. If Ah Huot is able to master more ADL skills, he would be able to reduce his dependency on his mother in caring for him.

What Is Activities of Daily Living (ADL)?

ADL are essential activities that we perform in our daily lives. Most children with disabilities have difficulties performing self-care. The nature of the disability, the child’s strengths, environment, and family support all contribute to the child’s level of independence.

ADL skills training should start early in life. However, if your child is now older and has yet to master self-care completely, it is still possible to begin the process or continue with the training.

Why Is It Important to Learn ADL Skills?

Participation in everyday life has a very significant influence on our health and well-being. It is important that we help develop ADL skills in children and encourage them to be independent, thus decreasing their dependence on caregivers.

Activity Analysis of ADL

Each ADL is assessed and then broken down into several steps. The skills required to complete each step are then identified. This way, we are able to determine the child’s ability to perform each step.

After the activity analysis, we will then formulate interventions focusing on steps where the child experiences difficulties. For example, if the child has difficulty with Step #3 (in Table 1) due to poor sitting balance, intervention plans can include sitting balance exercises.

Activity analyses can be done regularly to monitor your child’s progress. Every step in the activity analysis table can be graded according to the level of independence or amount of assistance needed by the child as shown in Table 2.

If you are unsure of how to do an activity analysis, consult your child’s occupational therapist.

Intervention Strategies

A variety of teaching strategies are used to train each individual. Here are some strategies you can use at home to develop your child’s ADL skills.

1. Forward / Backward Chaining

For this method, the child masters each step before progressing to the next one.

In forward chaining, the child begins an activity by completing the first step with your guidance when necessary. Once the child has mastered the step completely, s/he will then proceed to learn the next step.

In backward chaining, after progressively completing the steps of an activity with your guidance, the child is then asked to complete just the last step. Once the child has mastered the last step, the child will then be required to complete the step before that one. This is repeated until all the steps have been mastered. Backward chaining provides your child with a sense of accomplishment once s/he finishes the entire activity.

2. Grading Steps

Once the child acquires skill in any particular step, the expectation increases and the level of difficulty of the step can gradually be upgraded. Conversely, if the child is unable to complete the skill set for a step, the difficulty should be downgraded. Grading can include the following:

Modifying Step Demands

a. Completing the step with lower or higher quality.

Examples of downgrade (lower quality): Using a larger or looser T-shirt instead of a fitting one.

Examples of upgrade (higher quality): Using shirts with larger buttons instead of smaller ones to make it easier to manipulate.

Provision for Promptings and Cues (downgrading)

Reduce the number of parts or steps in any instruction. For example, instead of saying “Go and pour a cup of water to drink it by yourself”, you should say “Go to the kitchen”, “take a cup from the shelf”, “bring the jar nearer to you”, “pour the water into the cup”, “put the jar back”, and “drink your water”.

Give instructions slowly.

Repeat instructions when needed.

b. Visual aids — Using picture cards as a prompt or as a representation of the sequence of steps can be used to help your child complete the steps. Visual aids can be used to supplement verbal cues.

• Provision of Physical Assistance (downgrading)

Physical assistance is provided when both verbal and visual cues are inadequate. We can use hand-over-hand facilitation to guide the child physically.

Hand-over-hand facilitation is done by holding the child’s hand and guiding him/her to perform the steps in an activity.

• Fading (upgrading) Fading is a training procedure in which physical assistances, as well as verbal and visual prompts are gradually withdrawn. This is done in the hope that the step can be performed without supporting prompts or assistance.

3. Modelling

Involves showing the child an actual example of what has to be done, to help the child visualise what is required of him/her.

4. Shaping

The simulation of action(s) of an activity. For instance, objects can be passed between one’s legs to a person positioned behind him/her. This shaping activity prepares individuals for cleaning after toileting.
Shaping must always be related to a functional activity at the end of the session. In other words, if you want to teach your child eating, conduct the shaping activities before meal time, so that they can practice the skills beforehand.

5. Cognitive Behavioural Strategies

Use positive reinforcements (rewards)

Rewards motivate the child to participate in the activity.

a. Use rewards to reinforce the desired ADL skill and/or to maintain a learned skill.

b. Give lots of praises. Praises help increase your child’s self-esteem and motivation to be independent

Avoid using punishments when the child performs a step wrongly

This discourages them from further trying and learning.

6. Creating a Learning Environment at Home

Setting up a physical environment

a. Set up a safe and conducive environment. You can do so by:

• Removing clutter to create sufficient space for movement.

• Keeping dangerous items such as sharp tools and detergents out of your child’s reach.

• Ensuring that hot water systems are kept at low temperatures when not in use; using a hot water flask that has an auto lock mechanism to prevent scalding.

b. If your child has epilepsy:

• Install sliding bathroom doors which can be opened from the outside in the event that your child falls against the closed door during an epileptic fit.

• Teach your child to close the bathroom door but not to lock it. An “in use” sign can be hanged outside the door when the bathroom is occupied.

c. Positioning

• It is important that the child is in a relaxed and well-balanced position, with minimum environmental distractions when facilitating steps in an activity.

Creating a Routine

Routines give the child a sense of control and allow him/her to know what to expect next.

Involvement of Family

The family’s beliefs on the importance of the child’s independence will impact the provision of opportunities for him/her to practice and in turn will affect his/her learning.

7. Use of Assistive and Adaptive Devices

If the strategies mentioned above cannot be carried out successfully, consider using assistive and adaptive devices. (e.g. Using a long handed reacher to scrub the back during showering.)

Story of Ah Huat (continued)

Ah Huat is now more independent in managing his own ADL and is learning new skills. This has lightened the load for his mother, as well as his sister who will be tasked with taking care of him in the future.

MINDS is an All In Preferred Partner.

Movement for the Intellectually Disabled of Singapore (MINDS) is one of the largest Voluntary Welfare Organisations in Singapore, serving some 2,400 clients from past the age of six to their ripe old age. MINDS’ services include four special schools, three employment development centres, three day training and development centres, and one multi-service residential home.

This guide was originally published by MINDS’ Allied Health Professionals unit and republished with minor editorial amendments by All In.

All content found on the All In website, has been created for informational purposes only. The content is not intended to be a substitute for professional advice, diagnosis or treatment.